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Changes in Maximum Daily AF Duration, Stroke, and Mortality
Quick Takes
- Increased, compared to stable, AF duration in follow-up was associated with a greater risk of the combined endpoint of stroke or mortality after controlling for the baseline maximum daily AF duration group, CKD, and the individual components of CHA2DS2-VASc.
- Overall, these data suggest that progression of AF is associated with negative outcomes and that there may be threshold effects of baseline AF duration that benefit from enhanced rhythm control.
Study Questions:
What is the association between changes in maximum daily atrial fibrillation duration (MDAFD) and stroke or mortality in patients with cardiac implantable electronic devices (CIEDs)?
Methods:
The investigators linked the Optum de-identified electronic health record (EHR) data set (2007-2021) with the Medtronic CareLink heart rhythm database. Patients with CIEDs and health care activity recorded in the EHR were included, excluding those on oral anticoagulation. MDAFD was assessed 30 days post-implant (baseline period) and 30 days before censoring or an event. Hazard ratios (HRs) for the primary analysis were adjusted for components of CHA2DS2-VASc, baseline MDAFD category, and chronic kidney disease (CKD). Ischemic stroke events, first defined as hospital admission with ischemic stroke as the primary diagnosis, and mortality were abstracted from the EHR database.
The primary analysis of the current study was to evaluate associations between changes in MDAFD category and the combined endpoint of ischemic stroke or mortality. Cox proportional hazards models were used to compare the incidence of the primary endpoint between groups based on change in MDAFD. The Cox model for the primary endpoint was adjusted for baseline MDAFD category, the individual components of the CHA2DS2-VASc score, and presence of CKD.
Results:
Of 26,400 patients (aged 68 ± 13 years; follow-up 2.6 ± 1.6 years) analyzed, 2,544 (9.6%) had AF during baseline. Increased (vs. stable or decreased) MDAFD category in follow-up was associated with a higher adjusted rate of stroke and mortality (HR, 1.80; 95% CI, 1.61-2.01). There was no association between decreased MDAFD in follow-up and the combined endpoint (HR, 0.82; 95% CI, 0.68-1.00). Subgroup analysis by baseline MDAFD category demonstrated that increased MDAFD in follow-up was associated with a greater risk of stroke or mortality among patients with no AF at baseline, and decreased MDAFD in follow-up was associated with a lower risk of stroke or mortality among patients with baseline MDAFD of 1 to <5.5 hours and 5.5 to <23.5 hours.
Conclusions:
The authors report that in CIED patients not on oral anticoagulation, increased MDAFD in follow-up was associated with a higher rate of stroke and mortality.
Perspective:
This study reports that changes in AF burden over time are associated with risk of stroke and mortality. Specifically, increased, compared to stable, AF duration in follow-up was associated with a greater risk of the combined endpoint of stroke or mortality after controlling for the baseline MDAFD group, CKD, and the individual components of CHA2DS2-VASc. Overall, these data suggest that progression of AF is associated with negative outcomes and that there may be threshold effects of baseline AF duration that benefit from enhanced rhythm control. Furthermore, these data encourage continued monitoring of AF duration over time to enhance risk stratification and further inform treatment efforts.
Clinical Topics: Arrhythmias and Clinical EP, Atrial Fibrillation/Supraventricular Arrhythmias, Prevention
Keywords: Atrial Fibrillation, Implantable Devices, Ischemic Stroke, Risk
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